Lessons Learned from Transportation Incidents

1
Lessons Learned from Transportation Incidents

• James B Martz Logistics HSSE Advisor

2
What drove the process

• Having a few major incidents not only drove
  crisis management but cause Logistic Management
  to focus on prevention instead of reaction.
• BZ release in Ohio.
• Shut down major highway.
• Reportable releases.

3
Evolution of incident management

• Developed a system to managed major incidents or
  crisis management.
• Changed to managing behaviors and becoming
  proactive.
• Required Logistic Service Providers (LSP) to
  report near misses/pre-incident indicators.
• For injuries bumps, bruises.
• For product releases cups, drops.
• For accidents (derailments/groundings/dear
  miss).
• Number of incidents went from 30 to 400.

4
Resource allocation where to get the best bang
for the buck

• Need to rank each by class based on severity.
• Establish the classifications based on the
  incident types.
• Health, Safety, Material releases, Property
  damage, Public disruption, Business interruption.
• Develop definitions for each level of severity in
  each class.
• Severe, Major, Minor, Near-miss.

5
Major Root Causes

• Procedures not followed 70
• Reductions in workforce required operators to do
  more Multi-tasking.
• Inadequate procedures
• Lack of proper Management of Change.
• Equipment failures
• In some cases these can be further defined a
  Procedures not followed if
• equipment is fit for purpose.
• properly maintained w/ Preventive maintenance
  plan.
• And failure analysis is completed upon each
  failure.

6
Lessons Learned

• When LSP started to report near-misses we found
  that there were frequent events where
  intervention occurred that needed to be shared
  across similar activities.
• Operators accepted the practice of working
  through the incident just to get the product
  delivered.
• Barge pump design showed weakness in the seal
  design and shaft support.
• Led to pump design change (double-seal/seal-less).

7
Lessons Learned

• Equipment specifications vs. regulations.
• Standard / minimum regulations allowed excess
  equipment which provided possible locations for
  leaks.
• Elevated company standard.
• General service tank car to a Pressure car.
• Eliminated vacuum breakers.
• Eliminated sample taps.
• Eliminated pumps on transportation equipment.
• Eliminated hosed on trucks.
• Used dedicated equipment.

8
Lessons Learned

• As the LSP operators began to report they began
  to observe the transfer operations more closely.
• Operator intervention at the time of the failure
  provided better description of the event thus
  failure analysis provided engineering solution.
• Pressure testing connection prior to transfer.
• Pump design and construction.
• Change in operating procedures.

9
How to get Partner participation

• Need to have continued CONSISTENT reinforcement
  to report ALL incidents.
• To assess each incident for learning experiences.
• To share learning experiences to promote a
  continuous improvement.
• most importantly to drive down the severity of
  each incident.
• not necessarily to reduce the number of incident
  reported.

10
How we Share

• MIA Major Incident announcements
• Actual severity of 1 or 2
• Fatalities, Major environmental impact, Adverse
  reputation
• Web-based program shared world wide.
• HIPO High-Potential
• Actual severity less than 2 but had the potential
  to be severe.
• Lessons Learned document within 30 days.

11
Pitfalls to incident management

• Reporting can not have negative actions
• Reward LSP for reporting near-misses.
• Dont shoot the messenger.
• Share lessons learned with LSPs
• Logistics Safety Conferences.
• Incident feedback through lessons learned
  document.